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BOARD OF TRUSTEES �I JOAQUIN LOCAL HEALTH DI <br /> �RICT SERVING <br /> AI Crow,Pres. San Joaquin County <br /> Earl Pimentel,Vice Pres. 1601 East Hazelton Avenue City of Manteca <br /> Tommy Joyce,Secy. Stockton, California 95205 City of Escalon <br /> James F.Culbertson City of Lodi <br /> John D.Most.M.D. JOGI KHANNA, M.D., M.P.H., DISTRICT HEALTH OFFICER City of Tracy <br /> Virginia Mathews City of Ripon <br /> Thomas Schubert D.V.M. ENVIRONMENTAL HEALTH DIVISION San Joaquin County <br /> Daphne Shaw (209) 468-342o City of Stockton <br /> Harvey Williams,Ph.D. San Joaquin County <br /> AU-rHC3FR I ZAT I C]N TC] FRF=LEASE <br /> ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> 1 , THE UNDERSIGNED OWNER AND/OP, OPERATOR OF THE PROPERTY AND/OP, FACILITY <br /> LOCATED AT <7/0A AVO O ki 1,){. Gly /f ki <br /> ( IR (CITY) <br /> HEREBY AUTHORIZEEi ADDRESS) <br /> (LABORATORY <br /> DDRSlla rt�n �er / r�p�rU <br /> (LABORATORY or CONSOLTAND <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO THE SAN JOAQUIN LOCAL HEALTH <br /> DISTRICT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: 9L6-to/�fd_ k <br /> (IF APPLICABLE) <br /> OWNER,/OPERATOR: -Gfrru L <br /> ( LEASE RIHT) (TITLE) <br /> (SIGNAID ) <br /> ADDRESS: 916 Ail-qL 4 Or. <br /> (NAILING ADDRESS) <br /> (CITY) G (STATE) (ZIP) <br /> PHONE: (2-02) G 31 -,3168 <br /> DATE: <br /> EH 23 041 Revised 1/69 <br /> Administration Clinical Services Environmental Health Public Health Nursing <br /> 468-9400 468-9890 468-9420 468-9860 <br /> Air Pollution Community Services Laboratory WIC <br /> 468-3470 468-9820 468.3460 468-3280 <br /> AIDS Information 468.3820 <br />